Laparoscopic renal surgery.

Renal surgery, radical nephrectomy in particular, was historically the first application of laparoscopic techniques in urology. Since then, laparoscopy has been constantly evolving to claim its position in the surgical armamentarium of the urologist for the treatment of both malignant and benign diseases of the kidney and upper urinary tract. Over the years of increasing surgical experience and exposure, along with the evolution in the techniques and instruments used, laparoscopy has emerged as an equally effective and even more attractive alternative to open surgery for certain indications. The currently available load of literature is able to prove beyond any doubt the oncologic efficacy and minimal morbidity of laparoscopy for the treatment of renal masses in the form of radical or partial laparoscopic nephrectomy and nephroureterectomy. On the other hand, one can claim that laparoscopy is not far from replacing open surgery for the management of benign conditions such as ureteropelvic junction obstruction and donor nephrectomy. This review on laparoscopic renal surgery will discuss the major applications, indications, techniques and outcomes of laparoscopy in the contemporary management of benign and malignant renal diseases while focusing on its benefits and drawbacks compared to open surgery.

Major ABO incompatible BMT in children: determining what residual volume of donor red cells can safely be infused following red cell depletion.

Major ABO incompatible BM transplantation carries a risk of acute haemolysis. Red cell depletion reduces this risk but not all incompatible RBC (iRBCs) are removed and in children the residual volume can be significant relative to body weight. We sought to determine the volume of iRBCs that can be safely given to children. All patients receiving fresh BM from a donor with a major ABO blood group mismatch between January 2000 and July 2013 at the Hospital for Sick Children, Toronto, were included. Seventy-eight patients were identified. The median volume of iRBCs transfused was 1.6 mL/kg (range 0.1-10.6 mL/kg). Thirty-five patients had minor haemolytic events and five patients had clinically significant adverse events. Two patients, who received 3.66 and 3.9 mL iRBCs/kg, developed renal impairment and in one case hypoxia and hyperbilirubinaemia. One patient had mild hypotension that resolved with i.v. fluid. Two patients developed hypotension secondary to sepsis and unrelated to BM infusion. Although signs of haemolysis occur, with appropriate hydration and monitoring of renal function, clinically significant adverse events related to the infusion of ABO incompatible BM are rare, and, in this study, were only seen in patients receiving >3 mL/kg of iRBCs per kg.

Laparoscopic nephrectomy in patients with end-stage renal disease and autosomal dominant polycystic kidney disease.

Autosomal dominant polycystic kidney disease (ADPKD) is often characterized by end-stage renal disease (ESRD) and problems including pain, hematuria, and infection. Open nephrectomy is curative; however, the morbidity of the procedure is considerable. Between 1995 and 1998, 11 laparoscopic nephrectomies were performed on nine symptomatic patients (five men and four women) with ESRD and ADPKD. Two patients underwent a staged bilateral laparoscopic nephrectomy. All patients presented with abdominal or flank pain and an abdominal mass. Other clinical problems included hypertension in eight patients, urinary tract infections in two patients, and gross hematuria in one patient. Seven patients were receiving long-term dialysis treatment, and two patients had undergone prior renal transplantation. Patients were evaluated for preoperative and postoperative pain, analgesic use, hospital course, and convalescence. The overall average operative time was 6.3 hours, with an average estimated blood loss of 153 mL. Eight nephrectomy specimens were removed by morcellation, and three specimens were removed intact through a 7- to 12-cm incision. The average hospital stay was 3 days, and the average time to normal activity was 5 weeks. With a mean follow-up of 31 months, all nine patients reported elimination of their preoperative pain based on a pain analogue score. Six major and two minor complications occurred, including blood transfusion, a vena cavotomy, splenic cyanosis, pulmonary embolism, clotted arteriovenous fistula, and brachial plexus injury. Incisional hernias occurred in two of the three patients who underwent open removal. One patient noted improvement, and two patients noted resolution of their hypertension postoperatively. Laparoscopic nephrectomy in patients with ADPKD and ESRD offers an effective alternative to open nephrectomy to manage renal-related pain. This procedure provides the benefits of minimal intraoperative blood loss, minimal postoperative pain, brief hospital stay, and rapid convalescence.

Advances in laparoscopic urology, Part I. History and development of procedures.

Many of the recent applications of laparoscopy to urologic surgery have demonstrated the feasibility of these techniques to complete the intended diagnostic or therapeutic objectives and provide the patient with a more comfortable and shorter recuperative period. Ongoing laboratory and clinical research continues to expand the field of laparoscopic urologic surgery in terms of therapeutic and reconstructive techniques. The second part of this review will explore the more innovative applications of laparoscopic urology and the impact this may have on the practice and art of urology.

Endoscopic management of persistent lymphocele following laparoscopic pelvic lymphadenectomy.

OBJECTIVE: To report an alternative form of management of a persistent lymphocele that was unresponsive to percutaneous drainage and ethanol sclerotherapy. METHODS: Herein is described the technique of dilating the previously established percutaneous drainage tract to facilitate insertion of a flexible ureteroscope. Through this instrument electrosurgical fulguration of the lymphocele cavity was performed. RESULTS: The patient had complete resolution of the lymphocele cavity on computed tomography (CT) scan and remains asymptomatic at six months of follow-up. CONCLUSIONS: Flexible ureteroscopic access and fulguration of a lymphocele proved to be a safe and effective method of obliterating the lymphocele cavity.

Comparison of transvaginal versus laparoscopic bladder neck suspension for stress urinary incontinence.

OBJECTIVES: The purpose of this retrospective review was to determine the feasibility of treating anatomic female stress urinary incontinence (SUI) with a retropubic laparoscopic bladder neck suspension. Also, we compared the clinical course and results of the transvaginal bladder neck suspension (VBNS; Raz) and laparoscopic bladder neck suspension (LBNS) among a group of patients of similar age and American Society of Anesthesiologists rating. METHODS: Nineteen patients undergoing a retropubic LBNS (E.M.M.) were compared with 23 patients undergoing a Raz VBNS (C.G.K.) operated on during the same time period for anatomic SUI. All patients were assessed for their age, preoperative bladder capacity, preoperative postvoid residual, operative time, estimated blood loss, length of hospital stay, postoperative analgesia requirement, time required to resume a normal voiding pattern, complications, and recurrence rate of the SUI. RESULTS: The operative time for the LBNS is longer than the VBNS (124 versus 44 minutes). The LBNS patients required significantly less postoperative parenteral analgesia (6.3 versus 15.6 mg morphine sulfate), and a shorter time to resume a normal voiding pattern (0.6 versus 13 days) compared with the VBNS patients. The overall success rate of the two procedures was similar at 3 months, 6 months, and 12 months of follow-up. CONCLUSIONS: Retropubic LBNS is a technically feasible surgical procedure for patients with anatomic SUI. Compared with the VBNS, the LBNS is associated with minimal postoperative discomfort, no need for suprapubic urinary diversion, and a rapid return to normal activities. The short-term success rate of the LBNS appears to be similar to that for the VBNS.

Laparoscopic pyeloplasty for secondary ureteropelvic junction obstruction: preliminary experience.

OBJECTIVES: To identify whether laparoscopic pyeloplasty is a reasonable treatment option for secondary ureteropelvic junction (UPJ) obstruction. METHODS: Since March 1994, we have performed laparoscopic pyeloplasties for secondary UPJ obstruction on 4 symptomatic patients ranging in age from 26 to 39 years. Prior failed procedures included antegrade endopyelotomies (3) and acucise endopyelotomies (3). Two patients underwent two prior endopyelotomies. Techniques of laparoscopic reconstruction included Anderson-Hines dismembered (3) and Culp-Deweerd flap (1) procedures. Repairs were performed with interrupted and running 3.0 and 4.0 Vicryl sutures using intra-corporeal knots and Lapra-Ty absorbable suture clips. RESULTS: Average operating time was 530 minutes (range, 465 to 645), which included preoperative cystoscopic placement of an external 7 F occlusion balloon catheter into the renal pelvis and placement of an internal double pigtail ureteral stent at the conclusion of the procedure. Average blood loss was 111 cc (range, 75 to 150). All 4 patients were found to have anterior crossing vessels intraoperatively. Average postoperative hospital stay was 4 days (range, 3 to 7). All 4 patients have a patent, nonobstructed UPJ by either Whitaker test or diuretic renography at an average of 3.3 months postoperatively (range, 1 to 5). Average return to normal activity was 4.5 weeks (range, 3 to 8). Utilizing an analogue pain scale, 2 of the patients are pain-free, and the other 2 are improved (45% and 85%) at an average of 8 months (range, 2 to 12) postoperatively. One patient developed stones in the renal pelvis and required percutaneous nephrolithotomy 10 weeks postoperatively. CONCLUSIONS: Laparoscopic pyeloplasty appears to be feasible and effective, although a technically challenging operative procedure for treating secondary (postendopyelotomy) UPJ obstruction. Further clinical experience and long-term follow-up are needed.

Retroperitoneoscopy: the Washington University Medical School experience.

OBJECTIVE: To describe our initial experience with balloon dilatation of the retroperitoneum. METHODS: In 12 patients undergoing laparoscopic renal surgery, the retroperitoneum was dilated using the technique of balloon dilatation. This technique is described and the operative procedure performed in each patient is outlined. The postoperative recovery data and complications are also presented. RESULTS: This procedure provided excellent exposure of the anatomic structures within the retroperitoneal space and simplified the surgical dissection by staying out of the abdominal cavity. CONCLUSIONS: Access to the retroperitoneal space is easily and quickly performed utilizing the technique of balloon dilation and may minimize the risk of injury to peritoneal organs.

Fascial closure of laparoscopic port sites: a new technique.

The laparoscopic operative procedure is not complete until the port sites are closed with a fascial suture. Herein, we report a simple new technique that uses a venous catheter for suture placement and direct laparoscopic visualization to secure the abdominal wall fascia and peritoneum.

Laparoscopic nephrectomy for renal neoplasms.

Laparoscopic nephrectomy has been shown to be an effective minimally invasive technique for treating benign renal disease requiring surgical excision. However, its application to approach renal malignancy has been limited. Herein, we report on 8 patients with renal tumor who underwent a laparoscopic nephrectomy. All kidneys were removed within Gerota's fascia, and in 3 patients with upper pole tumors, the adrenal gland was also removed en bloc. With limited follow-up of seven to thirty-five months (mean 14 months), there has been no clinical or radiographic evidence of tumor recurrence. We believe that laparoscopic radical nephrectomy with strict adherence to oncologic surgical principles is a practical, less invasive alternative in select patients with renal tumors.

Laparoscopic gonadectomy in a case of testicular feminization.

Laparoscopy provides a minimally invasive technique for the accurate diagnosis of intersex problems and may also provide the opportunity for therapeutic management of these patients. Herein, we report our management of a patient with complete testicular feminization, by laparoscopic bilateral gonadectomy of fully developed intra-abdominal testes.

Laparoscopic creation of a catheterizable cutaneous ureterovesicostomy.

Nephrectomy and creation of a cutaneous ureterovesicostomy for intermittent catheterization of the bladder traditionally requires two surgical procedures performed through separate incisions. Herein we report completion of these procedures using a transperitoneal laparoscopic approach, with the ureterovesicostomy stoma created at one of the laparoscopic working ports. The clinical course was remarkable for a shortened postoperative hospitalization (48 hours) with minimal incisional pain, and an excellent long-term result with complete bladder emptying and resolution of urinary infections. Laparoscopic application of the Mitrofanoff principle for creation of a catheterizable cutaneous ureterovesicostomy combines the advantages of both, allowing optimal preservation of ureteral vascularity, minimal morbidity, and efficient bladder evacuation.

Transperitoneal nephrectomy for benign disease of the kidney: a comparison of laparoscopic and open surgical techniques.

OBJECTIVE: The objective of this study was to compare the results of laparoscopic nephrectomy for benign disease to open surgical nephrectomy for benign disease. METHODS: Twenty consecutive patients undergoing laparoscopic nephrectomy for benign disease were compared with 23 patients undergoing open surgical nephrectomy for benign disease and with 29 patients undergoing a donor nephrectomy. Data were collected in the following areas: patient age, anesthetic risk, operative time, estimated blood loss, postoperative time to resume oral intake, parenteral analgesics, oral analgesics, hospital stay, complications, and convalescence. Information was obtained through chart review, telephone interviews, and mailed questionnaires. RESULTS: Compared with open surgical nephrectomy, laparoscopic nephrectomy resulted in a statistically significant longer operative time; however, it afforded a statistically significant decrease in postoperative ileus (open group), hospital stay (both groups), oral analgesics (donor group), and convalescence (both groups). The incidence of complications was 15 percent in the laparoscopic group and 0 percent in the two open surgical groups; the majority of complications occurred during the initial seven laparoscopic procedures. CONCLUSIONS: Laparoscopic nephrectomy is a more time-consuming procedure than open surgical nephrectomy. Also, early in one's experience with this technique, the complication rate is higher than with open surgery. However, despite the newness of the technique, it results in significant benefits to the patient: decreased postoperative pain, shorter hospitalization, and more rapid convalescence.

Laparoscopic pneumodissection: initial clinical experience.

OBJECTIVES: We evaluated the efficacy of a new laparoscopic dissecting instrument that fires intermittent bursts of high-pressure carbon dioxide to separate tissue along natural planes. METHODS: The pneumodissector (PD) was used in 2 patients undergoing laparoscopic procedures. Serum creatinine and bicarbonate were measured before and after the procedure, and arterial blood gases were measured before, during, and after use of the PD. Subjective assessment of the ease of dissection with the PD by the first assistant was recorded. RESULTS: Acidosis and hypercarbia were not observed with use of the PD. The PD facilitated dissection along the iliac vessels, around the kidney, and in the renal hilum. CONCLUSIONS: The PD is a feasible method for rapid, blunt dissection during laparoscopic procedures.

Laparoscopic nephrectomy for renal cell cancer: evaluation of efficacy and safety: a multicenter experience.

OBJECTIVES: Although laparoscopic radical nephrectomy is a safe and minimally invasive alternative to open surgery, the long-term disease-free outcome of this procedure has not been reported. We evaluated our experience with the laparoscopic management of renal cell carcinoma to assess the clinical efficacy of this surgical modality. METHODS: Between February 1991 and June 1997, 157 patients at five institutions were retrospectively identified who had clinically localized, pathologically confirmed, renal cell carcinoma and had undergone laparoscopic radical nephrectomy. Operative and clinical records were reviewed to determine morbidity, disease-free status, and cancer-specific survival. Of the patients followed up for at least 12 months (n = 101), 75% had an abdominal computed tomography scan at their last visit. RESULTS: The mean age at surgery was 61 years (range 27 to 92) and all patients were clinical Stage T1-2,NO,MO. Fifteen patients (9.6%) had perioperative complications. During a mean follow-up of 19.2 months (range 1 to 72; 51 patients with 2 years or more of follow-up), no patient developed a laparoscopic port site or renal fossa tumor recurrence. Four patients developed metastatic disease, and 1 patient developed a local recurrence. The 5-year actuarial disease-free rate was 91%+/-4.8 (SE). At last follow-up, there were no cancer-specific mortalities. CONCLUSIONS: The laparoscopic surgical management of localized renal cell carcinoma is feasible. Short-term results indicate that laparoscopic radical nephrectomy is not associated with an increased risk of port site or retroperitoneal recurrence. Longer follow-up is necessary to compare long-term survival and disease-free rates with those of open surgery.

Laparoscopic complications in markedly obese urologic patients (a multi-institutional review)

OBJECTIVES: Significant obesity is considered to be a relative contraindication to laparoscopic surgery. This study reviews the complications encountered in massively obese patients undergoing urologic laparoscopic surgery. METHODS: Body mass index (BMI) was used as an objective index to indicate massive obesity. Eleven institutions compiled retrospective data on 125 patients having a BMI greater than 30. Procedures performed included 76 pelvic lymph node dissections, 14 nephrectomies, 7 bladder neck suspensions, and 28 miscellaneous procedures. RESULTS: For the group as a whole, the mean BMI was 35.1 (range 30.1 to 57.2). Mean operative time was 202 minutes (range 60 to 480). Conversion to open surgery occurred in 15 of the 125 patients (12%). Complication rates (minor and major) were 22% (27 occurrences in 125 patients) intraoperatively and 26% (33 occurrences in 125 patients) postoperatively. The major complications included 2 trocar injuries to abdominal wall vessels, 1 bladder injury, 3 peripheral nerve injuries, 1 dysrhythmia, 1 deep vein thrombosis, 1 wound seroma, 1 nephrocutaneous fistula, 1 incisional hernia, and 1 death. CONCLUSIONS: In this review, complication rates for urologic laparoscopic surgery on massively obese patients were higher than in the general population undergoing laparoscopic surgery (0.3% to 21%).

Survey of neuromuscular injuries to the patient and surgeon during urologic laparoscopic surgery.

OBJECTIVES: Laparoscopy may be complicated by neuromuscular injuries, both to the patient and to the surgeon. We used a survey to estimate the incidence of these injuries during urologic laparoscopic surgery, to assess risk factors for these injuries, and to determine preventive measures. METHODS: A survey of neuromuscular injuries associated with laparoscopy submitted to 18 institutions in the United States was completed by 18 attending urologists from 15 institutions. RESULTS: From among a total of 1651 procedures, there were 46 neuromuscular injuries in 45 patients (2.7%), including abdominal wall neuralgia (14), extremity sensory deficit (12), extremity motor deficit (8), clinical rhabdomyolysis (6), shoulder contusion (4), and back spasm (2). Neuromuscular injuries were twice as common with upper retroperitoneal as with pelvic laparoscopy (3. 1% versus 1.5%). Among patients with neuromuscular injuries, those with rhabdomyolysis were heavier (means 91 versus 80 kg) and underwent longer procedures (means 379 versus 300 minutes), and those with motor deficits were older (means 51 versus 42 years of age). Of the surgeons, 28% and 17% reported frequent neck and shoulder pain, respectively. CONCLUSIONS: Although not common, neuromuscular injuries during laparoscopy do contribute to morbidity. Abdominal wall neuralgias, injuries to peripheral nerves, and joint or back injuries likely occur no more frequently than during open surgery, but risk of rhabdomyolysis may be increased. Positioning in a partial rather than full flank position may reduce the incidence of some injuries. Measures to reduce neuromuscular strain on the surgeon during laparoscopy should be considered.

Retroperitoneal and pelvic extraperitoneal laparoscopy: an international perspective.

OBJECTIVES: To assess technical preferences and current practice trends of retroperitoneal and pelvic extraperitoneal laparoscopy. METHODS: A questionnaire survey of 36 selected urologic laparoscopic centers worldwide was performed. RESULTS: Twenty-four centers (67%) responded. Overall, 3988 laparoscopic procedures were reported: transperitoneal approach (n = 2945) and retroperitoneal/extraperitoneal approach (n = 1043). Retroperitoneoscopic/extraperitoneoscopic procedures included adrenalectomy (n = 74), nephrectomy (n = 299), ureteral procedures (n = 166), pelvic lymph node dissection (n = 197), bladder neck suspension (n = 210), varix ligation (n = 91), and lumbar sympathectomy (n = 6). Mean number of total laparoscopic procedures performed in 1995 per center was 41 (range 5 to 86). Major complications occurred in 49 (4.7%) patients and included visceral complications in 26 (2.5%) patients and vascular complications in 23 (2.2%). Open conversion was performed in 69 (6.6%) patients, electively in 41 and emergently in 28 (visceral injuries, n = 16; vascular injuries, n = 1 2). Retroperitoneoscopy/extraperitoneoscopy is gaining in acceptance worldwide: in 1993, the mean estimated ratio of transperitoneal laparoscopic cases versus retroperitoneoscopic/ extraperitoneoscopic cases per center was 74:26; however, in 1996 the ratio was 49:51. CONCLUSIONS: Retroperitoneoscopy and pelvic extraperitoneoscopy are important adjuncts to the laparoscopic armamentarium in urologic surgery. The overall major complication rate associated with retroperitoneoscopy/extraperitoneoscopy was 4.7%.

Carbon dioxide absorption during laparoscopic pelvic operation.

BACKGROUND: Several factors may influence the degree of carbon dioxide (CO2) absorption during laparoscopy. Hypercapnia as a result of excessive CO2 absorption may have adverse clinical effects. STUDY DESIGN: To identify factors associated with increased CO2 absorption, we retrospectively calculated the CO2 elimination in 65 adult patients who underwent operative pelvic laparoscopy. Increases in CO2 elimination were assumed to be indicative of CO2 absorption. The most commonly performed procedures were bladder neck suspension and pelvic lymphadenectomy. The median insufflation time was 165 minutes. An extraperitoneal approach was taken in 32 percent of the patients. RESULTS: Of patients evaluated with postoperative roentgenograms of the chest, 35 percent had subcutaneous emphysema and 9 percent had pneumomediastinum with or without pneumothorax. Multiple factorial analysis of the variance revealed that the extraperitoneal approach, development of subcutaneous emphysema, and increased duration of insufflation were independently associated with a greater increase in peak CO2 elimination. Insufflation time and subcutaneous emphysema had stronger effects in the extraperitoneal group. CONCLUSIONS: The risk factors for hypercapnia can be identified. Careful consideration of the patient's ability to tolerate hypercapnia should be made when planning extraperitoneal laparoscopy, especially if the procedure is likely to be prolonged. The clinical development of subcutaneous emphysema should alert the surgeon to the possibility of subsequent hypercapnia.

Laparoscopic pneumodissection: results in initial 20 patients.

BACKGROUND: The efficiency of laparoscopic procedures has been hindered by a lack of instrumentation for blunt tissue dissection. We evaluated here the efficacy of a new 5-mm laparoscopic dissecting instrument, a pneumodissector. This instrument allows the surgeon to use short bursts of high-pressure carbon dioxide to bluntly dissect fatty tissue. STUDY DESIGN: In 20 patients undergoing a variety of laparoscopic procedures, a 5-mm laparoscopic pneumodissector was used. Subjective assessment of the efficacy of the instrument was recorded. In addition, acid-base changes were measured by blood gas determination, and serum chemistries were obtained before, during, and after the procedure. RESULTS: The pneumodissector enhanced dissection of the kidney, ureter, and major blood vessels and shortened the operative time for laparoscopic nephrectomy. Although statistically significant changes in acidbase values occurred with use of the pneumodissector, these changes were not clinically significant and were no different than what is normally seen during carbon dioxide pneumoperitoneum. CONCLUSIONS: Laparoscopic pneumodissection is a safe and efficacious technique for rapid blunt tissue dissection.